Health plan rate approval

AN ACT Relating to providing consistency in the rate approval 1
process for individual and small group market health plans; amending 2
RCW 48.18.110 and 48.46.060; and reenacting and amending RCW 3
48.44.020. 4
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:5
Sec. 1. RCW 48.18.110 and 2008 c 303 s 1 are each amended to 6
read as follows: 7
(1) The commissioner shall disapprove any such form of policy, 8
application, rider, or endorsement, or withdraw any previous approval 9
thereof, only: 10
(a) If it is in any respect in violation of or does not comply 11
with this code or any applicable order or regulation of the 12
commissioner issued pursuant to the code; or 13
(b) If it does not comply with any controlling filing theretofore 14
made and approved; or 15
(c) If it contains or incorporates by reference any inconsistent, 16
ambiguous or misleading clauses, or exceptions and conditions which 17
unreasonably or deceptively affect the risk purported to be assumed 18
in the general coverage of the contract; or 19
(d) If it has any title, heading, or other indication of its 20
provisions which is misleading; or 21
H-1325.1
HOUSE BILL 1957
State of Washington 69th Legislature 2025 Regular Session
By Representatives Schmick and Dufault
Prefiled 02/11/25. Read first time 02/12/25. Referred to Committee
on Health Care & Wellness.
p. 1 HB 1957
(e) If purchase of insurance thereunder is being solicited by 1
deceptive advertising. 2
(2) In addition to the grounds for disapproval of any such form 3
as provided in subsection (1) of this section, the commissioner may 4
disapprove any form of disability insurance policy if the benefits 5
provided therein are unreasonable in relation to the premium charged. 6
Rates, or any modification of rates effective on or after July 1, 7
2008, for individual and small group market health benefit plans may 8
not be used until ((sixty)) 60 days after they are filed with the 9
commissioner. ((If)) For an individual health benefit plan, if the 10
commissioner does not disapprove a rate filing within ((sixty)) 60 11
days after the insurer has filed the documents required in RCW 12
48.20.025(2) and any rules adopted pursuant thereto, the filing shall 13
be deemed approved. For a small group market health benefit plan, if 14
the commissioner does not disapprove a rate filing within 60 days 15
after the insurer's rate filing is complete, the filing shall be 16
deemed approved.17
Sec. 2. RCW 48.44.020 and 2008 c 303 s 2 and 2008 c 217 s 51 are 18
each reenacted and amended to read as follows: 19
(1) Any health care service contractor may enter into contracts 20
with or for the benefit of persons or groups of persons which require 21
prepayment for health care services by or for such persons in 22
consideration of such health care service contractor providing one or 23
more health care services to such persons and such activity shall not 24
be subject to the laws relating to insurance if the health care 25
services are rendered by the health care service contractor or by a 26
participating provider. 27
(2) The commissioner may on examination, subject to the right of 28
the health care service contractor to demand and receive a hearing 29
under chapters 48.04 and 34.05 RCW, disapprove any individual or 30
group contract form for any of the following grounds:31
(a) If it contains or incorporates by reference any inconsistent, 32
ambiguous or misleading clauses, or exceptions and conditions which 33
unreasonably or deceptively affect the risk purported to be assumed 34
in the general coverage of the contract; or 35
(b) If it has any title, heading, or other indication of its 36
provisions which is misleading; or 37
(c) If purchase of health care services thereunder is being 38
solicited by deceptive advertising; or 39
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(d) If it contains unreasonable restrictions on the treatment of 1
patients; or 2
(e) If it violates any provision of this chapter; or3
(f) If it fails to conform to minimum provisions or standards 4
required by regulation made by the commissioner pursuant to chapter 5
34.05 RCW; or 6
(g) If any contract for health care services with any state 7
agency, division, subdivision, board, or commission or with any 8
political subdivision, municipal corporation, or quasi-municipal 9
corporation fails to comply with state law. 10
(3) In addition to the grounds listed in subsection (2) of this 11
section, the commissioner may disapprove any contract if the benefits 12
provided therein are unreasonable in relation to the amount charged 13
for the contract. Rates, or any modification of rates effective on or 14
after July 1, 2008, for individual and small group market health 15
benefit plans may not be used until ((sixty)) 60 days after they are 16
filed with the commissioner. ((If)) For an individual health benefit 17
plan, if the commissioner does not disapprove a rate filing within 18
((sixty)) 60 days after the health care service contractor has filed 19
the documents required in RCW 48.44.017(2) and any rules adopted 20
pursuant thereto, the filing shall be deemed approved. For a small 21
group market health benefit plan, if the commissioner does not 22
disapprove a rate filing within 60 days after the insurer's rate 23
filing is complete, the filing shall be deemed approved.24
(4)(a) Every contract between a health care service contractor 25
and a participating provider of health care services shall be in 26
writing and shall state that in the event the health care service 27
contractor fails to pay for health care services as provided in the 28
contract, the enrolled participant shall not be liable to the 29
provider for sums owed by the health care service contractor. Every 30
such contract shall provide that this requirement shall survive 31
termination of the contract. 32
(b) No participating provider, insurance producer, trustee, or 33
assignee may maintain any action against an enrolled participant to 34
collect sums owed by the health care service contractor.35
Sec. 3. RCW 48.46.060 and 2008 c 303 s 3 are each amended to 36
read as follows: 37
(1) Any health maintenance organization may enter into agreements 38
with or for the benefit of persons or groups of persons, which 39
p. 3 HB 1957
require prepayment for health care services by or for such persons in 1
consideration of the health maintenance organization providing health 2
care services to such persons. Such activity is not subject to the 3
laws relating to insurance if the health care services are rendered 4
directly by the health maintenance organization or by any provider 5
which has a contract or other arrangement with the health maintenance 6
organization to render health services to enrolled participants.7
(2) All forms of health maintenance agreements issued by the 8
organization to enrolled participants or other marketing documents 9
purporting to describe the organization's comprehensive health care 10
services shall comply with such minimum standards as the commissioner 11
deems reasonable and necessary in order to carry out the purposes and 12
provisions of this chapter, and which fully inform enrolled 13
participants of the health care services to which they are entitled, 14
including any limitations or exclusions thereof, and such other 15
rights, responsibilities and duties required of the contracting 16
health maintenance organization. 17
(3) Subject to the right of the health maintenance organization 18
to demand and receive a hearing under chapters 48.04 and 34.05 RCW, 19
the commissioner may disapprove an individual or group agreement form 20
for any of the following grounds: 21
(a) If it contains or incorporates by reference any inconsistent, 22
ambiguous, or misleading clauses, or exceptions or conditions which 23
unreasonably or deceptively affect the risk purported to be assumed 24
in the general coverage of the agreement; 25
(b) If it has any title, heading, or other indication which is 26
misleading; 27
(c) If purchase of health care services thereunder is being 28
solicited by deceptive advertising; 29
(d) If it contains unreasonable restrictions on the treatment of 30
patients; 31
(e) If it is in any respect in violation of this chapter or if it 32
fails to conform to minimum provisions or standards required by the 33
commissioner by rule under chapter 34.05 RCW; or 34
(f) If any agreement for health care services with any state 35
agency, division, subdivision, board, or commission or with any 36
political subdivision, municipal corporation, or quasi-municipal 37
corporation fails to comply with state law. 38
(4) In addition to the grounds listed in subsection (2) of this 39
section, the commissioner may disapprove any agreement if the 40
p. 4 HB 1957
benefits provided therein are unreasonable in relation to the amount 1
charged for the agreement. Rates, or any modification of rates 2
effective on or after July 1, 2008, for individual and small group 3
market health benefit plans may not be used until ((sixty)) 60 days 4
after they are filed with the commissioner. ((If)) For an individual 5
health benefit plan, if the commissioner does not disapprove a rate 6
filing within ((sixty)) 60 days after the health maintenance 7
organization has filed the documents required in RCW 48.46.062(2) and 8
any rules adopted pursuant thereto, the filing shall be deemed 9
approved. For a small group market health benefit plan, if the 10
commissioner does not disapprove a rate filing within 60 days after 11
the insurer's rate filing is complete, the filing shall be deemed 12
approved.13
(5) No health maintenance organization authorized under this 14
chapter shall cancel or fail to renew the enrollment on any basis of 15
an enrolled participant or refuse to transfer an enrolled participant 16
from a group to an individual basis for reasons relating solely to 17
age, sex, race, or health status. Nothing contained herein shall 18
prevent cancellation of an agreement with enrolled participants (a) 19
who violate any published policies of the organization which have 20
been approved by the commissioner, or (b) who are entitled to become 21
eligible for medicare benefits and fail to enroll for a medicare 22
supplement plan offered by the health maintenance organization and 23
approved by the commissioner, or (c) for failure of such enrolled 24
participant to pay the approved charge, including cost-sharing, 25
required under such contract, or (d) for a material breach of the 26
health maintenance agreement. 27
(6) No agreement form or amendment to an approved agreement form 28
shall be used unless it is first filed with the commissioner.29
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